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CEN > 18 CEN: neurological emergencies > Flashcards

18 CEN: neurological emergencies Flashcards

18 items on exam

1
Q

What is cerebral perfusion pressure?

A

CPP = MAP - ICP

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2
Q

What is normal CPP?

A

70-90 mmHg

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3
Q

In head injury, what is CPP goal?

A

> 60 mmHg

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4
Q

What is normal ICP?

A

< 15 mmHg

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5
Q

What is the Monro-Kellie doctrine?

A

The sum of volumes of brain (80%), CSF (10%), and intracranial blood (10%) is constant.

An increase in one should cause a decrease in one or both of the remaining two.

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6
Q

How is level of consciousness assessed?

A

AVPU

Alert
Verbal stimulus, responds
Pain, required for response
Unresponsiveness

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7
Q

Based on GCS, what is severity of head injury?

A

minor head injury 13-15
moderate injury 9-12
severe <8 (Need to secure airway)

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8
Q

What is the FOUR score?

A

The Full Outline of UnResponsivness (FOUR) score is a neurological assessment score.

Its benefit over preexisting scores is its evaluation of brainstem reflexes and respiratory pattern which may allow better assessment of patients with severe neurologic impairment or ventilated patients.

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9
Q

What diagnostic test is performed with s/s of stroke?

A

check blood sugar and treat as needed

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10
Q

What are s/s of Wernicke’s encephalopathy?

A

Confusion/confabulation- unintentional fabrication of memory,

Ataxia- impaired balance,

Nystagmus- repetitive uncontrolled eye movements

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11
Q

What are the differences in posturing?

A

Flexion - decorticate (cerebrum)
Extension - decerebrate (brainstem)

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12
Q

What can pupils tell us about neurological status?

A

PINPOINT - opioids (consider naloxone if apneic too), or exposure to organicphosphates pesticides or chemical warfare agent (CWA);

Nystagmus - drugs, tumor.

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13
Q

Where is CSF leakage found with brain injury? What should be done about draininage?

A

check the ears (otorrhea) and nose (rhinorrhea)

CSF will be clear drainage -
to confirm check for glucose (66% of serum glucose) which will form a halo

Do NOT pack, just let it drain, place sterile nasal drip pad to prevent infection, not to prevent drainage.

Instruct patient to not blow nose. Do NOT insert an NG tube.

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14
Q

What is the Babinski reflex?

A

Babinski - fanning of toes abnormal finding in adults.



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15
Q

What is the Oculocephalic reflex?

A

“Doll’s eyes”

  • if brainstem is intact, the eyes deviate to opposite side head moved to (NORMAL).

No movement of eyes = brain death.

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16
Q

What is the Oculovestibular reflex?

A

“cold caloric”

  • eyes look toward ear irrigated (NORMAL),

-no response in brain death.

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17
Q

What are the 12 cranial nerves?

A
  1. Olfactory nerve (CN I), smell
  2. optic nerve (CN II), vision
  3. oculomotor nerve (CN III), most eye mvmt
  4. trochlear nerve (CN IV), moves eyes to look at nose
  5. trigeminal nerve (CN V), face sensation and mastication
  6. abducens nerve (CN VI), abducts the eyes
  7. facial nerve (CN VII), facial express and taste => Bell’s palsy
  8. vestibulocochlear nerve (CN VIII), hearing and balance
  9. glossopharyngeal nerve (CN IX), taste, gag reflex
  10. vagus nerve (CN X), gag reflex and parasympathetic innervation
  11. accessory nerve (CN XI), shoulder shrug
  12. hypoglossal nerve (CN XII), swallowing and speech
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18
Q

Which nerve is affected by Bells palsy?

A

cranial nerve 7

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19
Q

Which nerve is affected by trigeminal neuralgia?

A

cranial nerve 5

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20
Q

What are s/s of multiple sclerosis? Treatment?

A

demyelination of axons leads to weakness, unsteady gait, and altered sensation in extremities and face;

treated with steroids and immunosuppressants (interferon).

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21
Q

What is Myasthenia gravis? S/s?
Dx? Tx?

A

Myasthenia gravis - autoimmune affecting women 20-30;

affects acetylcholine binding sites leading to muscle fatigue, ptosis (drooping eyelids), dysphagia, and respiratory paralysis;

DX with Tensilon, have Atropine at bedside in case of cholinergic crisis;

TX with Neostigmine. Atropine if excessive Neostigmine taken.

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22
Q

What is Parkinson’s disease?
S/s? Tx?

A

Parkinson disease - chronic degenerative disease affecting the dopamine pathway;

S/S: tremor at rest, facial “mask”, “cogwheel” rigidity; bradykinesia (slowness of movement and speed or progressive hesitations/halts)

TX: Carbidopa (levodopa)

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23
Q

What is Amyotrophic lateral sclerosis (ALS) “Lou Gehrig Disease” and S/s?

A

Amyotrophic lateral sclerosis (ALS) “Lou Gehrig Disease” - genetic disorder that leads to progressive loss of voluntary muscle control (grip strength) but retains intelligence and personality.

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24
Q

What is Guillain-Barre syndrome and S/s?

A

Guillain-Barre syndrome - damage to myelin sheath leading to a tingling prickling sensation in extremities, loss of DTR and difficulty walking, urinary retention, and ASCENDING symmetrical weakness/paralysis; monitor respiratory effectiveness; care is supportive.

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25
Q

Likely dx for sudden onset of headache with peak intensity “explosive” “worst of life” within minutes?

A

SAH

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26
Q

S/S of meningitis?

A

nuchal rigidity and fever (meningitis),

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27
Q

What should be suspected with head trauma and decreased LOC?

A

intracranial bleed

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28
Q

An escalating headache can be?

A

a tumor

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29
Q

What is Temporal arteritis “giant cell arteritis” and S/S? Dx? Tx?

A
  • inflamed temporal artery (palpable cord-like) in age > 50,

-resulting in a throbbing headache in temporal area and jaw pain (with chewing), fever, and temporary
unilateral vision loss;

ESR and C-reactive protein increased; treated with corticosteroids.

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30
Q

What does a tension headache feel like? Best intervention?

A

Tension - “band-like” pain across forehead.

Teach relaxation techniques.

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31
Q

S/s of a migraine? Important teaching point for patient?

A

unilateral pulsating pain, photophobia and phonophobia, N/V, possible aura.

Teach to journal to determine triggers.

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32
Q

What are cluster headaches like? Initial treatment?

A

-excruciating, unilateral (periorbital/temporal), episodic (multiple per day, short-lived), excessive tearing (lacrimation) and nasal congestion on affected side.

Treat with oxygen initially.

33
Q

What is meningitis
S/S?
Presentation in infants?
Precautions?

A

-acute inflammation of the meninges from virus or bacteria (group B streptococcus or Neisscria meningitides - meningococcal)

S/S: Altered LOC, fever, headache, nuchal rigidity, photophobia, Kernig’s and Brudzinski’s legs pull up when head is bent) signs.

Infants - bulging fontanelles, opisthotonos (backward arch), and high-pitched cry.

Don PPE and isolate patient immediately on droplet precautions.

TX: Assume bacterial and institute isolation immediately, antibiotics STAT, assist with lumbar puncture (LP) - side-lying position preferred.

Bacterial CSF - high ICP pressure (measured in LP), cloudy, low glucose.

34
Q

What is Meningococcemia?

A

Meningococcemia - non-blanching petechial rash on torso/legs.

35
Q

Causes of seizures?

A

electrolyte disorders (low sodium and glucose), alcohol withdrawal, hypoxia, meningitis, illicit drugs, trauma, tumor, stroke, febrile (rapid rise in temperature, familial).

36
Q

Classifications of seizures?

A

partial, complex, general, convulsive, non-convulsive, febrile. Infants demonstrate repetitive movement “bicycling”.

37
Q

What is Status Epilepticus?

A

Status Epilepticus: series of or continuous seizure lasting 5 minutes that is unresponsive to traditional therapy;

sequelae of hypoxia, acidosis, and hypoglycemia.

38
Q

Treatment for seizures?

A

TX: Mainstay of treatment is benzodiazepines (lorazepam).

Monitor airway and safeguarding from injury; identify and treat the cause (antipyretics); continue lorazepam (Ativan) and administer phenytoin (Dilantin) or fosphenytoin (Cerebryx);
Thiamine and dextrose; consider paralytics. Mix Dilantin in 0.9% NS only and infuse no faster than 50 mg/minute, monitor closely for infiltration. Cardiac, BP, and RR monitoring during infusion and 20 minutes post infusion. Educate on seizure medication (Keppra) - causes drowsiness, and avoid alcohol.

39
Q

To dx stroke, what should be ruled out?

A

hypoglycemia, atypical migraines, Bell palsy, Lyme disease facial paralysis (facial palsy, ually one side)

40
Q

What is most common stroke? cause?

A

Ischemic (92% from embolus or thrombus formation)
HX: of uncontrolled HTN, atrial fibrillation, diabetes, prostatic heart valves

41
Q

S/S of stroke?

A

unilateral facial and extremity weakness/paralysis (contralateral to clot), dysarthria (slurred speech), dysphagia (difficulty swallowing, drooling), expressive (difficulty speaking) or receptive (difficulty understanding spoken word) aphasia, and visual disturbances (homonymous hemianopsia)

42
Q

How is a stroke dx?

A

Non-contrast head CT within 45 minutes to r/o bleed (does not show ischemia).

43
Q

Tx for stroke? How is tPA infused?

A

iv. TX: peripheral rTPA (alteplase) within 3-4.5 hours or intra-arterial reperfusion or mechanical thrombectomy to revascularize the ischemic penumbra.

Exclusion criteria: evidence of intracranial bleed, tumor, or head trauma; AV malformation; current internal bleeding; platelets < 100,000 mml. DO NOT GIVE TPA

44
Q

What is dosing for TPA? What should be monitored?

A

**rTPA 0.9 mg/kg (maximum 90 mg), bolus 10% of dose over 1 minute, remainder as a drip over the next hour (waste extra prior to administration). Flush with NS at same rate once infusion is complete.

Monitor for decreased LOC, and bleeding during infusion.

BP control for SBP > 185 mm Hg or DBP > 110 mm Hg.

45
Q

S/S of Transient ischemic attack (TIA - mini stroke)?
Treatment?

A

Transient ischemic attack (TIA - mini stroke) - warning sign - 10-15% experience a stroke within 3 months with 50% of those within next 48 hours.

Symptoms typically resolve within 10-20 minutes, classified as resolving within 24 hours.

Reversible ischemic neurologic deficit (RIND) is a cerebral infarct that lasts > 24 hours, but <72 hours.

Manage BP, blood sugar, and coagulation.

46
Q

What are the 2 types of hemorrahagic strokes?

A

intracerebral and subarachnoid

47
Q

S/S of intracerebral hemorrahagic stroke?
Tx?

A

rapid onset of headache and focal deficits

-neurosurgical consul;
-manage ABC’s and BP;
-administer vitamin K, FFP, and/or TXA to stop bleeding.
-Reverse anticoagulants with Kcentra and vitamin K for coumadin OR Andexxa for Xarelto.

48
Q

Subarachnoid hemorrhage causes?
S/S? TX?

A

Subarachnoid hemorrhage - usually caused by aneurysm or A V malformation;

S/S: explosive or “Worst HA of my life in 74%, altered LOC in 53%, N/V in 77%, photophobia, focal deficits and nuchal rigidity in 35%.

TX: Manage ABC’s, raise head of bed, control SBP, and prepare for surgical intervention (clipping or coiling), calcium-channel blockers (Nimodipine).

49
Q

Primary and secondary head trauma/ brain injury?

A

Primary injury from the event - MVC, fall, sports, assaults.

Secondary brain injury from cerebral edema from hypotension, hypoxia, hypercarbia.

50
Q

What are the Degrees of brain injury?

A
  1. Mild - GCS 13-15 with loss of consciousness < 30 minutes and no deficits.
  2. Moderate - GCS 9-12 with loss of consciousness and focal deficits.
  3. Severe - GCS of 8 or less with significant loss of consciousness, abnormal pupils, and posturing.
51
Q

Scalp lacerations are _______ so __________.

A

Very vascular, apply pressure

52
Q

What is a complication of a concussion?

A

post concussive syndrome - cognitive impairment, slowed reaction time, memory difficulties.

Medical clearance for return to play, too early return - secondary impact syndrome from
minor injury may lead to death.

53
Q

What are head injury precautions?

A

acetaminophen only for pain, no narcotics; no caffeine to
stimulate brain; cognitive brain rest and graduated return to play.

54
Q

What is Diffuse Axonal Injury (severe diffuse TBI)?
S/S?

A

the shearing (tearing) of the brain’s long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull.

Widespread microscopic hemorrhage (no focal lesion) leads to immediate and prolonged coma (reticular activating system affected), hypertension, hyperthermia, excessive sweating, and abnormal posturing.

55
Q

What are Basilar Skull Fractures and S/S?
What should be assessed if drainage present?

A

-Fracture of the bones at the skull leading to altered LOC, combative behavior, headache, and vomiting.

Assessing cerebral spinal fluid (CSF) - “halo” test for bloody drainage, glucose test for clear drainage.

56
Q

What is the difference b/w anterior and middle fossa fracture?
Intervention?

A

Anterior fossa fracture - “raccoon’s eyes” - periorbital ecchymosis and rhinorrhea, anosmia.

Middle fossa fracture - “battle’s sign” - mastoid ecchymosis and otorrhea, rupture: tympanic membrane.

→Place sterile drip pad under nose and over ears to prevent infection, do not pack ears and nose, let it drain, no NG tube.

57
Q

What is difference b/w Epidural and Subdural?

A

Epidural Hematoma
* Arterial bleed
* Sudden loss of consciousness, or
* Short period of unconsciousness followed by lucid period, and subsequent deterioration
* dilated nonreactive pupil on ipsilateral side
* younger population

Subdural Hematoma
* Venous bleed
* Progressively decreasing LOC
* Elderly or alcoholic
* Shaken Impact Syndrome

58
Q

Mgmt of ↑ ICP?

A

*Monitor intracranial pressure and keep < 20 mm Hg.

*Elevate the HOB to 30-45°, neutral alignment (chin to umbilicus), avoid hip flexion (increases intra-abdominal pressure, which increases ICP).

*Maintain Systolic BP 100 mm Hg or above (110 in older adult) with vasopressors to maintain cerebral perfusion pressure (CPP) 50-70 mm Hg.

*Maintain Sp02 above 94% and CO2 at 35-37 mm Hg (low normal).

*Administer the osmotic diuretic Osmitrol (Mannitol) 1 gram/kg IV bolus or hypertonic saline 3%, 7.5%, or 10% IV, effective if urine output increases.

*Avoid hypotonic solutions.

*Monitor sodium and serum osmolality closely, especially if administering Mannitol.

*Keep hemoglobin up since RBCs carry oxygen using 1:1:1 transfusion with plasma, platelets, and RBCs; reverse anticoagulants and administer cryoprecipitate to reduce bleeding.

*Avoid venous compression of neck (remove rigid cervical collar).

*Maintain normothermia by treating fever aggressively.

*Dark, low-stimulus environment, limit visitors, speak softly.

*Control agitation with benzodiazepines and short-acting opioids so you can assess frequently.

59
Q

What is SCIWORA?

A

Spinal cord injury w/o radiographic injury

→seen in children under age 8
Need MRI to assess edema

60
Q

What is NEXUS criteria for?
What are the criteria?

A

NEXUS (National Emergency X-Radiography Utilization Study)

-to decide which trauma patients do not require cervical spine imaging

NSAID to remember:
-Neuro deficit
-Spinal tenderness
-AMS
-Intoxication
-Distracting injury

What are the five low-risk criteria used by the Nexus rule?
The five criteria of the NEXUS are:
1) no posterior midline cervical tenderness;
2) no evidence of intoxication;
3) normal level of alertness (i.e. the patient is alert and oriented to person, place, time, and event);
4) no focal neurological deficit; and
5) no painful distracting injuries (e.g. long‐bone fracture)

61
Q

What is a “chance” fracture?

A

T12-L2 fracture from hyperflexion “lap belt” only injuries, with concurrent hollow organ bowel or stomach injury

62
Q

S/S for complete spinal cord injury?

A
  1. Lose all motor/sensory function and reflexes below level of injury.
  2. Loss of bowel and bladder function.
  3. Priapism, poikilothermia (difficulty to regulate body temperature), loss of proprioception (sense of relative position of one’s own body parts and strength of effort being employed).
63
Q

What should monitored with SCI?
complications?

A

TX: Protect airway, monitor breathing effectiveness and assist breathing as needed, keep warm, remove from backboard early to protect skin early, insert gastric tube to prevent ileus, insert urinary catheter if not contraindicated.

Complications: Pressure ulcers, DVT to pulmonary embolus, pneumonia.

64
Q

What is Caude equina syndrome?

A
  • cord compression of L5-S1 “horse-tail” from fall onto coccyx, resulting in “saddle anesthesia”, sciatica-type back pain, bowel, bladder, and sexual dysfunction.
65
Q

Pt physical abilities with cervical Spinal Cord Injury?

A

Tetraplegia or Quadriplegia when all four limbs are involved.

66
Q

Pt physical abilities with C1-C4 Spinal Cord Injury?

A

Requires 24-hour-a-day care, may be able to use powered wheelchair.

67
Q

Pt physical abilities with C5-C8 Spinal Cord Injury?

A

May be able to breath on their own and speak normally, needs assistance with ADL’s. Little or no control of bowel or bladder.

68
Q

Pt physical abilities with thoracic Spinal Cord Injury?

A

Paraplegia, can use a manual wheelchair, learn to drive a modified car, stand in standing frame.

69
Q

Pt physical abilities with lumbar Spinal Cord Injury?

A

May walk with braces, no control of bowel and bladder.

70
Q

Pt physical abilities with sacral Spinal Cord Injury?

A

Most able to walk, no control of bowel and bladder.

71
Q

What functions are lost with anterior cord?

A

Loss of motor function, pain, crude touch, & temperature; retains proprioception.

72
Q

What functions are lost with Brown-sequard cord?

A

(2 words - 2 sides)
Transverse hemisection (Stab or GSW)
Loss of motor function on side of injury (ipsilateral)
Loss of pain & temperature on opposite side of injury (contralateral)

73
Q

What functions are lost with central cord?

A

Loss of motor & sensory function, more pronounced in arms than legs (walk to table, but can’t eat)

74
Q

What functions are lost with posterior cord?

A

Loss of proprioception, vibration, fine touch, & fine pressure. Intact motor function

75
Q

What happens with HR in neurogenic shock? why?

A

Injury at T6 or above with loss of sympathetic nervous system (SNS) innervation leaving unopposed parasympathetic nervous stimulation, prevents compensatory increase in heart rate in response to hypotension.

76
Q

What are S/S of neurogenic shock?

A

S/S: Warm, flushed skin with full pulses, hypotension, and BRADYCARDIA (or lack of expected tachycardia), temperature instability (poikilothermia). Venous pooling in periphery

77
Q

What is TX for neurogenic shock?

A

TX: Spinal motion restriction; support airway and breathing; augment vascular tone with IV fluids, vasopressors, and positive inotropes.

78
Q

What kind of shock is neurogenic?

A

distributive, maldistribution of blood

79
Q

What is Autonomic Dysreflexia? Tx?

A

Complication of SCI above T6.

Noxious stimulus leads to massive sympathetic nervous system response, resulting in a sudden onset of severe HTN, pounding headache, nausea, nasal congestion, anxiety, flushed face, sweating with piloerection (“goose bumps”).

TX: Identify and treat cause - over-distended bladder, bowel impaction, skin pressure, infection, ingrown toenail; lower blood pressure.

CEN (10 decks)

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